Personally Owned Vehicle Business Use Agreement
This form is to be filled out and signed by the employee.
As evidence of insurance required in paragraph 3, please request your insurance carrier, broker or agent to provide a certificate of
insurance which shows the name and address of your carrier and your broker or agent, the make of your vehicle, its vehicle
identification number, your policy number and the name of the person for whom the policy is written.
Agreement between ____________________________________, hereafter referred to as The Company, and the undersigned
employee-driver of a personally owned vehicle used for Company business.
Employee ___________________________________________ Social Security Number __________________________________
Authorization to use a personally owned vehicle for Company business is granted under the following conditions:
1. The above named employee-driver shall comply with all motor vehicle laws and regulations of the states in which the
employee travels on Company business including laws and regulations covering vehicle registration, driver’s license and
state vehicle inspections.
2. It is Company policy that employees who drive or ride as passengers while on Company business will use available
passenger restraints at all times when the vehicle is in motion.
3. The vehicle to be used for driving on Company business shall be insured for at least the minimum limits or the compulsory or
financial responsibility required by the state in which the vehicle will be operated. In the event there is no compulsory
insurance statute within the state of licensing and/or operation, the vehicle must be insured for an amount consistent with the
Company’s risk management program for both bodily injury and property damage.
4. The Company will reimburse the employee-driver for authorized mileage on Company business within a calendar year at the
then prevailing rates. The Company will also pay bridge, ferry and road tolls and parking charges when these expenses are
incurred while the vehicle is being used on Company business.
5. The employee-driver shall keep accurate records and submit reports as required by the Company covering mileage, expenses
6. The Company shall be notified of any and all accidents in which the driver is involved while driving the vehicle on Company
7. The Company is authorized to verify the accident record of any employee-driver.
8. If the personally owned vehicle covered by this agreement is not owned by the employee-driver, the following shall be
The undersigned, who is lawful owner of : __________________________ ___________________ ________________
Make of Vehicle Body Style Year
_____________________________ Herby grants permission to : _________________________________________________
Serial Number Name of Employee
to use this vehicle when engaged in business for the Company. The undersigned owner agrees to waive any
claims against the Company arising out of the use of the vehicle as aforsaid.
Date: ________________________ Signature of Owner: ________________________________________________________
9. This authorization may be terminated by the Company at any time.
I have read, understand and agree to comply with the above conditions authorizing me to drive a personally owned vehicle on
Date: ________________________ Employee’s Signature: _______________________________________________________
Date: ________________________ Manager: __________________________________________________________________